ISMA CME PLANNING DOCUMENT

The updated ACCME Criteria require more detailed documentation assessing how a CME accredited activity is planned and evaluated. This planning document will assist in structuring your activity and facilitate evaluation of its effectiveness following the completion of the activity. This form is based on mandated criteria to confirm that the CME activity is in full compliance with ACCME requirements. Please use the Checklist to help assist in the completion of this document.

Directions

For a :Lve Activity: The Planning Committee should complete this document based on the entire activity or should select at least two presentations or sessions from the course and answer the questions relative to those presentation(s)/session(s).

For Regularly Scheduled Series (eg. Grand Rounds): The Planning Committee should complete this document based on the entire series OR should select at least two topics from the series and answer the questions relative to that presentation(s).

Please contact the CME Office should you need assistance in completing this document. PLEASE TYPE

1. / Title of Activity:
2. / Location:
3. / Date(s):/Days
4. / Number of Category 1 Credits Requested:
5. / Number of Participants Expected: / MD / Other
6. / Define Target Audience:
7. / Course Director Name:
Title:
Department/Organization Name:
Phone: / Fax:
Email:
8. / Planning Committee Members (must include at least one UVM MD faculty member):
1. / Name: / Dept/Org.
2. / Name: / Dept/Org.
3. / Name: / Dept/Org.
9. / Contact person responsible for required materials, including sign-in sheets and evaluations:
Name: / Phone:
Address: / Fax:
Email:

Definitions

Competence - “Knowing how to do something” “… a combination of knowledge, skills and performance..the ability to apply knowledge, skills and judgment in practice.” “The simultaneous integration of knowledge, skills, and attitudes required for performance in a designated role and setting.”

Performance- “What one actually does, in practice.”

Professional Practice Gap - “The difference between actual and ideal performance and/or patient outcomes.” Identify a deficiency in knowledge, competence, or performance based on data from one or more sources.

Scope of Practice - “The range or breadth of a physician’s actions, procedures, and processes.”

Criterion:The activity planning committee identifies professional practice gaps relative to the scope of the intended audience.

10.
Identify a professional practice gap. Document the source of the gap utilizing national trend/state level data; institutional QA data; core competency requirements; patient care indicators; published literature, etc...
Attach Documentation / Identify a minimum of 2 gaps and source for each:

Criterion:The planning committee incorporates into CME activities the educational needs (knowledge, competence, or performance) that underlie the professional practice gaps of their own learners.

11.
Based on the identified practicegap above, describe a knowledge, competence or performance need. E.g. Do physicians need to know something, learn how to do something, develop a strategy for doing something, or need to change something in their practice? / Describe need:

Criterion:The planning committee generates activities/educational interventions that are designed to change competence, performance, or patient outcomes (course objectives).

12.
Based on the need, specifyhow the activity will promote changes to meet that need (i.e. to change competence, performance or patient outcomes – what the learner should expect to achieve). / Please list at least 3 course objectives:

Criterion:The planning committee generates activities/educational interventions around content that matches the learners’ current or potential scope of professional activities.

13.
Describe (in general) the scope of practice of your physician target audience. e.g. do they serve a specific patient group or multiple groups? Do they have both clinical and non-clinical responsibilities? Are there areas of medicine that they practice which are outside their specialty? / Describe scope of practice:

Criterion: The planning committee selects educational formats for the activity that are appropriate for the setting, objectives and desired results of the activity.

14.
What format(s) will be employed for the activity (e.g. didactic, small groups, virtual patients, self-directed learning, panel discussions, hands-on workshops)? / Describe your format and how it meets your objectives:

Criterion:The planning committee developed the activity in the context of desirable physician attributes (ACGME Competencies).

15.
To what ACGME competency does the course/presentation relate?
Please check applicable area(s):
Patient Care
Medical Knowledge
Practice-based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Systems Based Practice.
Does the content relate to IOM, other competency, or another desirable physician attribute? E.g. AMA Code of Ethics? / Explain:

Criterion:The planning committee analyzes changes in learners’ competence, performance, or patient outcomes.

16.
How will you evaluate the success of your activity in affecting the change in physician competence, performance, and/or patient outcomes that you identified in planning the activity? (This can be in the form of pre and post activity questionnaires, QA or QI data, etc…)
Please attach sample evaluation LABEL THIS INFORMATION [ATTACHMENT A] / Describe your evaluation process:

Please refer to checklist for specifics on attachments B and C

17. / Budget – Please attach a proposed budget
LABEL THIS INFORMATION [ATTACHMENT D]
Amount of Tuition: / What does tuition include?
If tuition isnot charged, explain manner in which expenses will be covered?
18. / Commercial Support
Is there commercial support involved? / Yes / No

If Yes, provide a typed alphabetical listing of supporters and the type of support being provided, i.e., grant funding, exhibit fees, in-kind equipment contributions. ATTACH a signed Commercial Support Agreement Form for each supporter. LABEL THIS INFORMATION[ATTACHMENT E].Documentation that commercial support was acknowledged to the audience will be required.

19. Biographical Data Forms: Include for each presenter, planning committee chairperson, and each planning committee member.LABEL THIS INFORMATION [ATTACHMENT F].

20. FacultyDisclosurePolicyandForms:

Each of the speakers for this activity, planning committee chairperson and members, and course moderator, are required to review Indiana State Medical Association, Faculty Disclosure Policy and complete and sign a Disclosure Form and Attestation Form. Copies of these forms should be returned to the ISMA no later than one month prior to the activity. In addition, any relationship on the part of the physician must be disclosed to the audience. This must be done by, syllabus insert,verbal announcement or PowerPoint slide at the beginning of all presentations.This must be documented in the file, how disclosure is made.

Note: Disclosure and Attestation Forms must be completed (and signed) whether or not there is a financial interest with a commercial entity. The content of presentations must be balanced and free of commercial bias (multiple therapies should mentioned). All clinical recommendations must be based on the best available evidence.LABEL THIS INFORMATION [ATTACHMENT G].

Having a financial interest or other relationships with a corporate organization may not prevent aspeaker from making a presentation. However, the existence of the relationship must be made known to theplanning committee prior to the conference, so that any possible conflict of interest maybe resolved prior to the talk. LABEL THIS INFORMATION [ATTACHMENT H].

Documentation that disclosure issues have been resolved must be provided;documentation that disclosure information was made to audience must also be provided---This documentation must be submitted immediately following the activity.

Faculty please return this document promptly to the ISMA CME staff with your other forms. ISMA CME will use the results to evaluate its overall CME program (an ACCME requirement) and to plan for future ways to better serve you in designing an effective and successful activity.

This application has been reviewed and approved by your Department/Organization/Planning Committee.

Name (PLEASE PRINT OR TYPE) / Signature / Date
Planning Committee CME Chairperson

Please complete all application questions. Incomplete applications will be ineligible for AMA PRA Category 1 creditTMapproval and will be returned. Please allow 30 days for processing.

Approved by ISMA / Date
AMA PRA Category 1

Adopted: 9/09

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